CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 430 902.75 33383.25 36.98
Subtotal (Total Children Is Unduplicated) 430 902.75 33383.25 36.98
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.00 56.56 28.28
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.00 300.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 9.00 675.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.50 787.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.50 262.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.50 712.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 11.00 610.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 22.00 1650.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.00 185.00 185.00
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.00 114.54 57.27
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 7 7.00 509.46 72.78
MED-99215-OUTPATIENT VISIT, EST, 40 MINS 6 6.00 300.90 50.15
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.00 97.00 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 13 13.00 650.00 50.00
Subtotal (Total Children Is Unduplicated) 56 113.50 7459.84 65.73
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 19.00 950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 2 5.00 339.40 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 5.00 339.40 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 16.00 1086.08 67.88
Subtotal (Total Children Is Unduplicated) 13 45.00 2714.88 60.33
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Total 1061.25 43557.97 41.04
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Number of Children (Unduplicated) With at Least One Service 434
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Center 01
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 40 27.00 999.00 0.00
H 0 0.00 0.00 0.00
T 19 19.00 1306.75 1306.75
14 13.00 700.40 0.00
Other 347 192.00 7363.50 0.00
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Total 420 251.00 10369.65 1306.75
Center 04
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 190 148.75 5485.25 0.00
P 2 1.50 222.50 100.28
D 1 1.00 55.50 0.00
S 0 27.00 999.00 0.00
H 3 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
0 13.00 700.40 0.00
Other 0 192.00 7363.50 0.00
-------------------------------------------------
Total 196 411.25 16582.90 1857.03
Center 05
Flag Claims Units Chgs Paid
-------------------------------------------------
R 13 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 315 335.75 12404.25 0.00
P 0 1.50 222.50 100.28
D 0 1.00 55.50 0.00
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
17 27.00 1568.39 0.00
Other 0 192.00 7363.50 0.00
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Total 345 625.25 25065.90 1857.03
Center 06
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 239 466.50 17242.00 0.00
P 0 1.50 222.50 100.28
D 0 1.00 55.50 0.00
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
11 39.00 2209.12 0.00
Other 0 192.00 7363.50 0.00
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Total 250 768.00 30544.38 1857.03
Center 07
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 3 468.50 17316.00 0.00
P 0 1.50 222.50 100.28
D 0 1.00 55.50 0.00
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
0 39.00 2209.12 0.00
Other 0 192.00 7363.50 0.00
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Total 3 770.00 30618.38 1857.03
Center 10
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 220 645.75 24091.00 0.00
P 26 39.25 2797.00 2674.78
D 7 8.50 333.00 277.50
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
3 42.00 2412.76 0.00
Other 0 192.00 7363.50 0.00
-------------------------------------------------
Total 256 995.50 40449.02 4709.03
Center 51
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 14 654.75 24424.00 0.00
P 0 39.25 2797.00 2674.78
D 0 8.50 333.00 277.50
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
5 54.00 3209.44 0.00
Other 0 192.00 7363.50 0.00
-------------------------------------------------
Total 19 1016.50 41578.70 4709.03
Center 52
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.00 696.01 0.00
U 0 0.00 0.00 0.00
B 27 670.75 25057.50 0.00
P 1 39.50 2806.25 2684.03
D 0 8.50 333.00 277.50
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
2 56.00 3309.44 0.00
Other 0 192.00 7363.50 0.00
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Total 30 1034.75 42321.45 4718.28
Center 53
Flag Claims Units Chgs Paid
-------------------------------------------------
R 1 13.25 705.26 0.00
U 0 0.00 0.00 0.00
B 1 671.00 25066.75 0.00
P 0 39.50 2806.25 2684.03
D 0 8.50 333.00 277.50
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
0 56.00 3309.44 0.00
Other 0 192.00 7363.50 0.00
-------------------------------------------------
Total 2 1035.25 42339.95 4718.28
Center 54
Flag Claims Units Chgs Paid
-------------------------------------------------
R 0 13.25 705.26 0.00
U 0 0.00 0.00 0.00
B 23 683.50 25529.25 0.00
P 8 45.00 3009.75 2887.53
D 0 8.50 333.00 277.50
S 0 27.00 999.00 0.00
H 0 9.00 450.00 450.00
T 0 19.00 1306.75 1306.75
5 64.00 3861.46 0.00
Other 0 192.00 7363.50 0.00
-------------------------------------------------
Total 36 1061.25 43557.97 4921.78